Multiple Street Light Outage Reporting

Please provide the following information so that we may contact you, if needed, regarding this report. All fields with an asterisk are required.

Bold Fields Required

Personal Information

First NameoptionalLast Nameoptional Email(john@smith.com) Confirm Email CityCountyoptional PhoneExt.Please enter a valid 3-digit number for Area CodePlease enter a valid 3-digit number for City CodePhone number is required OR needs to be a valid 4-digit number

I am a City/County/Other Government Agency Employeeoptional

YesNoOne selection is required

If Yes, Agency/Titleoptional Total Count of Lights Being Reported (from 1 to 25)

Choose best description of situation optional

Lights are individually out / broken and are widely scattered across area.Lights are all grouped together in one area, but are individually out / broken.Lights are all together in one area and are out as a group (possible power outage or wiring problem).